Many of our clients have been asking about how to improve bone density. This is a good concern, as many middle age women are at risk for, or already have, osteoporosis. But this isn’t just a concern for women, as men can also have osteoporosis. Think you can tune out because you haven’t quite hit middle age? Think again young-ins.

Many studies show the most significant impact we have on building bone density is during your adolescence and young adulthood, and we reach peak bone mass between 25 and 30. For older adults, don’t think it’s too late, there is good Several studies have shown post-menopausal women in their 60-80s were able to increase bone density in response to exercise. 

Young adults should focus on building as much bone density as possible. Adults should focus on either maintaining the bone mass they have, slow down the rate of loss, or rebuild some bone that they’ve lost.

T-Scores or Falls?

Most concerned about bone density are focusing on improving their T score, but let’s not lose sight of the major issue. All of this bone density concern is really about one thing: reduce fractures. How do fractures mostly happen? They happen with falls. So what are the biggest factors related to falls? Strength, poor balance, cognitive decline, multiple medications, and fear of falling amongst others. Guess what one thing has the biggest impact on reducing the risk of falls, or at least improve the other factors? Resistance training! The higher the intensity and more dynamic, the better it will address all of the above factors.

Treatments that have shown to improve bone density or prevent/minimize the loss of bone include: Hormone replacement therapy, resistance training, and supplementation with calcium and vitamin D (only in combination with exercise) all have shown to be effective.

See the common theme? It’s resistance training. No matter what, resistance training must be part of your strategy if bones are in anyway important to you because it is not just about improving a test score, it’s about the function, as well.

 

What type of resistance training?

Clearly we need to focus on resistance training to affect bone mass. As our clients already know, you might realize that not all resistance training is created equal and you know that the dosage can be quite variable. Accordingly, it’s tough to find research to tell you exactly what works best.

Being a nerd, I’ve scurried through it all and found a few great studies that give us some answers. In the early 90s, researchers at Tufts showed that older adults, including frail folks in their 80s and 90s, were able to not only tolerate, but thrive on high intensity weight training, destroying the myth that high load activity was too much for brittle older adults. (Fiatarone, MA, et al. N Engl J Med 1994) This was influential in laying the groundwork for exploring the effects of higher load activity for older adults.

Given the variable responses reported in the literature for exercise increasing bone density, researchers at Arizona State in the early 2000s constructed a well-designed study to test different types of exercise in combination with other treatments (supplementation and hormone replacement therapy) and found that high intensity exercise combined with HRT and calcium supplementation had the best effect on improving bone density.

 

Interestingly, the study also found that only doing high intensity resistance training and supplementation also produced significant improvements, and weren’t significantly different from the group that had added HRT (Metcalf, et al ACSM’S Health and Fitness Journal, May/June 2001). This is important because it provided a rationale for those who were adverse to or unable to use HRT, they had a viable option for increasing bone density without it.

A meta-analysis showed that for all populations, resistance training at least attenuates the loss of bone density, and at best actually increases the amount of bone density. The trends also showed that high intensity (70-90% of maximum) was required to make this improvement (Zhao, et al. Osteoporos Int. 2015 May).

Another excellent study revealed even more clarity for what type of training should be done. Participants were females, average age of 68 with bone density T-scores less averaging –2.6 (very low bone density). One group did 5 exercises, 5 sets of 5 reps, at 80-85% of their maximum, which included dead lifts, squats, jumping chin-ups/drop landings, and overhead presses all under supervision 2x/week. The other worked out at home doing lunges, calf raises, delt raises, standing shrugs, balance exercises, and 15 minutes of walking 3x/week.

The results were nothing short of impressive. Bone density scores increased an average of .3% to 1.6% (depending on location) for the high intensity plus impact group, where as they decreased by 1.7%-2.5% in the control group. In addition, the high intensity plus impact group showed increased function and reduced fall risk factors compared to the control. Even better, there were no adverse effects of the high intensity treatment. (Watson, et al. Osteoporos Int. 2015 Dec)

A more recent study continued to show that resistance training is vital in improving bone density for young and older adults, and at worst can prevent the degree of bone density loss in older, frail adults. (Hong, et al. Endocrinol Metab (Seoul). 2018 Dec)

The consensus is clear: you must load your bones, and daily activities outside of resistance training are not enough.

 

So what does this all mean?

• If you care about improving bone density you must be doing resistance training, High intensity with impact is best.
• Even if you don’t increase bone density with resistance training, at the very least you are reducing the rate of bone loss.
• Regardless of its impact on bone density, the studies clearly show markers for function and reduced fall risk are greatly improved by resistance training.
• Supplementing with calcium and vitamin D is a good idea, but it won’t make much of a difference without resistance training.
• Hormone Replacement Therapy will likely help, but even if you elect not to use it, you can expect significant improvements with resistance training. This is something you need to discuss with your doctor to evaluate the pros and cons.
• Jumping may be a good impact activity to add to your routine. Depth jumps may be something you will benefit from assuming your strength and technique has progressed well enough to justify it.
• Stop being scared of lifting heavy. Dozens of research studies fail to show any of the horrible risks that people fear will happen to osteoporotic folks if you load them. That doesn’t mean you put a heavy barbell on the back of anyone with low T scores. Proper technique and progression is always critical, regardless of age. However, assuming proper mechanics, progression, and dosage, the body responds well to loading near maximum effort.

 

What if you can’t lift heavy?

If you are weak, less load is required to stimulate the bones and muscles. The key point is that the bones must be stimulated closer to their maximum ability. It takes a skilled pro to determine what that load is and if you are in pain, it’s important to resolve it quickly instead of hoping it goes away so that the problem isn’t compounded by allowing bones to weaken as well.

Also, keep in mind that loading other bones is possible even when the painful body part temporarily can’t be loaded. For example, if your right knee is painful, you can still load the hip, as well as the other leg, the spine, and arms. Don’t fall into the “all or nothing” trap when you are in pain.”

Have concerns about your own bone density and need help improving it? Click here, we can definitely help you out!

 

Here’s a quick story that you need to hear.

It explains why I have such a problem with the false notion that cardio training is something that only happens on a treadmill or bike, and that weight training somehow is not good for your heart.

Recently a patient came to see me for a severe back problem.

One of the worst I’ve seen.

Fortunately, I knew I could help him, and after a couple treatments there were noticeable improvements.

But he was extremely deconditioned. The muscle wasting from years of illness and inactivity was profound. He was going to need months of conditioning to reclaim adequate strength to support his spine and maintain the improvements he was getting from our therapy sessions.

Earlier in the year, he had a heart attack, and needed open heart surgery to clear the blockage.

He spent months and months going to “cardiac rehab”, which involved having to walk hunched over on a treadmill 3-5 x/week.

After cardiac rehab was exhausted, it was time for him to have his back checked out by me.

Clearly his strength and mobility were contributing to his back pain, and PT treatment was required.

However, since he exhausted his insurance benefit because of his 5 months in cardiac rehab, he couldn’t get treatment in PT.

The treatment that would have improved his strength, pain, bone density, posture, fall risks, AND cardiac health was not allowed because of one thing:

Misinformation.

The patient, cardiologist, and primary care practitioner wrongly believed, as so many others do, that cardiovascular training is limited to prolonged, sustained aerobic training on a machine.

If they were aware that resistance training is cardiovascular training, than he would have received the proper care that his insurance provides for.

This is not my opinion.

 It is fact that cardiovascular function and performance are improved by resistance training.

 It is a fact that risks of cardiac disease, including heart attack, are reduced by resistance training.

Some studies even show that resistance training is more effective than aerobic training for improving cardiac health.

Imprint this in your mind: resistance training is cardiac training.

Try this test: do 10 lunges, 10 rows, and 10 pushups. Check your heart rate. It’s elevated, right? Then you just did cardio. If it’s not, go to the hospital because something is really wrong.

If my patient received resistance training for true cardiac rehab, he would have been taking steps to concurrently increase muscle mass, improve bone density, improve strength, reduce fall risks, lower blood pressure,  lower cholesterol, lower stress, lower risk of depression, improve cognitive performance, AND improve cardiac performance and lower risk of subsequent heart attack, stroke, diabetes, and death! All the while, it would have addressed the underlying impairment related to his back pain.

He would undoubtedly been healthier and in less pain by now. It would have cost less too.

You would think that lecturing hospital systems, nurses, and physicians would help this. I do my best to inform them through my national lectures that have mostly PTs in attendance. So it’s mostly preaching to the choir. I would love to speak to local hospitals, but they are very territorial seeing me as a competitor to their outpatient services.

So I think the best option is you, the general public. Being empowered with information will help you and loved ones make better decisions about your care. You can tell your providers that they need to know this information: share this information. You can send them this email, or send them to my blog detailing the evidence of why resistance training is cardio. Even better, send them to one of my workshops.

Since I last wrote my article detailing the evidence of how resistance raining is cardiovascular training, there has been even more evidence showing this.

A recent Harvard study showed that those who were able to perform more than 40 pushups had a 96% lower risk of heart attack compared to those who were able to do 10 or less.  Yang J, Christophi CA, Farioli A, et al. Association Between Push-up Exercise Capacity and Future Cardiovascular Events Among Active Adult Men. JAMA Netw Open. 2019

Now, a few things to consider. First, the average age of the participants was 40 years old, and they were all men. So this doesn’t extrapolate to all populations. But is does reveal an interesting trend: strength tends to strongly correlate with risk of cardiac disease. And based on the studies reviewed here, the process of strengthening not only reduces cardiac disease, but it improves cardiac performance.

Hopefully the message is getting clearer for you: if you want to have a healthy heart, work on strength training. When you are super busy and overwhelmed, trying to figure out where to start, or what’s the least I can do to get the biggest benefit, start with resistance training.

At the very least, if you don’t enjoy running, sitting on a stationary bike, or plodding along on an elliptical, you can be assured that by doing strength training you are still working on improving your cardio.

If you want to incorporate resistance training into your routine but don’t know where to start, we are always here to help.